From the Guidelines
Patients with diabetes who are immunocompromised should receive comprehensive management, including annual influenza and pneumococcal vaccinations, to prevent complications and infections, as recommended by the most recent guidelines 1. The management of diabetes in immunocompromised patients involves a multifaceted approach, including blood glucose control, medication management, and prevention of infections.
- Blood glucose control is essential, with targets typically aiming for HbA1c <7% for most patients, though targets may be individualized based on patient characteristics and comorbidities.
- Medication options include metformin as first-line therapy, with additional agents like SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or insulin as needed based on glucose control and comorbidities.
- Immunocompromised diabetic patients should receive all recommended vaccinations, including annual influenza, pneumococcal vaccines (PCV13 and PPSV23), hepatitis B series, and COVID-19 vaccines, as supported by evidence from studies such as 1 and 1.
- Regular screening for complications is crucial, including quarterly HbA1c monitoring, annual comprehensive foot exams, eye examinations, and kidney function tests.
- Infection prevention strategies are vital, including meticulous hygiene, prompt attention to wounds, avoiding sick contacts, and seeking medical attention for fever or signs of infection, as emphasized in guidelines such as 1. These patients should maintain regular follow-ups with both endocrinology and infectious disease specialists as appropriate, with more frequent monitoring than typical diabetic patients due to their increased vulnerability to infections and complications. Key considerations in the management of immunocompromised diabetic patients include the potential for increased risk of infections, the need for careful monitoring of blood glucose levels, and the importance of preventive measures such as vaccinations and infection control strategies, as highlighted in studies such as 1 and 1.
From the Research
Diabetes and Infections
- Diabetes mellitus is associated with various types of infections, including skin, mucous membrane, soft tissue, urinary tract, respiratory tract, and surgical and/or hospital-associated infections 2.
- The immunocompromised state of diabetic patients, caused by uncontrolled hyperglycemia, impairs overall immunity and increases the risk of infections 2.
- Specific microbes are associated with each type of infection, and their presence indicates the type of infection, such as E. coli and Klebsiella for urinary tract infections 2.
Treatment of Diabetes
- SGLT2 inhibitors are a new class of oral antihyperglycemic agents that can be used as add-on therapy to metformin or as initial dual therapy with metformin in patients with higher glycated hemoglobin (HbA1c) levels 3.
- The combination of metformin and SGLT2 inhibitors can improve glycemic control with a low risk of hypoglycemia, but may increase the risk of metabolic acidosis 3.
- SGLT2 inhibitors have been shown to be effective in reducing hyperglycemia in patients with type 2 diabetes, with a low propensity to cause hypoglycemia 4.
Comparison of SGLT2 Inhibitors and Sulfonylureas
- SGLT2 inhibitors have been compared to sulfonylureas as second-line therapy in patients with type 2 diabetes inadequately controlled on metformin, with results showing similar glycemic efficacy but less hypoglycemia and greater reductions in weight and blood pressure with SGLT2 inhibitors 5.
- A meta-analysis of randomized controlled trials found that SGLT2 inhibitors led to a reduction in weight and blood pressure, but increased the incidence of genital tract infections compared to sulfonylureas 5.
- A cohort study found that SGLT2 inhibitors were associated with a reduced risk of all-cause mortality compared to sulfonylureas in patients with type 2 diabetes receiving metformin therapy 6.